- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.31 / $292.31 / $292.31
| Facility | | $292.31 | $292.31 | $292.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.71 / $292.31 / $311.20
| Professional | | $242.71 | $292.31 | $311.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $1,033.92 / $1,188.78
| Facility | | $100.00 | $1,033.92 | $1,188.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.20 / $290.20 / $290.20
| Professional | | $290.20 | $290.20 | $290.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.04 / $116.04 / $116.04
| Professional | | $116.04 | $116.04 | $116.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $3,472.00 / $9,239.00
| Facility | | $83.43 | $3,472.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.70 / $57.70 / $96.30
| Professional | | $57.70 | $57.70 | $96.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.20 / $290.20 / $290.20
| Professional | | $290.20 | $290.20 | $290.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.70 / $57.70 / $57.70
| Professional | | $57.70 | $57.70 | $57.70 |